Expert Critique

FROM THE AGA Reading Room

Michelle LongAssistant Professor of Medicine, Department of Medicine, Section of GastroenterologyBoston University School of MedicineBoston, MA

Older and younger patients infected with hepatitis C (HCV) have different characteristics, and treatment needs to be tailored accordingly. Older HCV patients, who have had a long duration of illness, are at risk for end-stage liver disease and liver cancer, but have a lower risk of re-infection after cure. Younger HCV patients have a shorter duration of illness and are less at risk of liver fibrosis in the short term. For younger HCV patients, the most immediate risk to their health relates to co-infection with other viruses, injection drug use, drug overdose, mental health issues, and lack of stable income and housing. For younger HCV patients, treatment must extend beyond direct-acting antiviral therapy to improve health and curb the risk of HCV infection and re-infection. Harm-reduction services such as access to needle exchanges to prevent transmission, opioid-substitution therapy for addition management of addictions, and ongoing counseling are needed, along with strong social services to stop the spread of HCV.

Full Critique

When it comes to hepatitis C virus (HCV), there are are two key groups at risk: Baby boomers, and younger birth cohorts with ongoing risk activities. This is something a Canadian research group calls "twin epidemics" and says that the younger cohort is not getting the attention they need.

Baby boomers are less likely to have ongoing risk activities, but they do have a relatively high burden of disease from infection acquired in the past. They are a clear group to target when it comes to screening and treatment programs, but the younger cohort have a variety of largely unmet needs that warrant attention if the spread of HCV is to be stemmed, according to Naveed Janjua, MBBS, DrPH, senior scientist at the British Columbia Centre for Disease Control in Canada.

"They are a unique group of individuals in which most new infections are happening," he told MedPage Today. "Treating them is more complicated than simply giving them medical therapy." He was lead author of a recent large study in BMC Infectious Diseases that elucidated the characteristics of the twin epidemics.

When researchers look at the causes of mortality among this younger cohort, deaths are often related to acquisition-related causes such as injection drug use and drug overdose. Baby boomers, on the other hand, are more likely to present later with HCV and to die from chronic diseases and liver-related causes.

The study used data from the British Columbia Hepatitis Testers Cohort, which includes all individuals tested for HCV or HIV at the BC Public Health Laboratory. Included were data on over 1.5 million people tested between 1990 and 2013, also linked to data on medical visits, hospitalizations, cancers, prescription drugs, and mortality.

The HCV-positivity rate (11.2%) was highest in the baby boomer birth cohort of 1945 to 1964, with new HCV diagnoses of infections acquired in the past declining over time. This group constitutes about 60% of all HCV infections, and new infections were more likely to be among those born between 1965 and 1984 (73%).

This younger cohort was much more likely than baby boomers to be HIV- or HBV-coinfected, to be socioeconomically disadvantaged, to have problematic drug and alcohol use, to have mental health illness, and to lack stable income and housing.

As well as having an increased risk of contracting HCV, this cohort is also more likely to transmit the disease via risky behaviors. In addition, this population is also at risk of re-infection, even if they are treated and cured of the disease, something the researchers showed in previous work.

However, Janjua noted, these various risks can be reduced if the social and medical needs of these individuals are addressed in a comprehensive one-stop-shop manner that affects risk activities -- such as mental health care, harm reduction, housing and economic stability.

"Our work has demonstrated that people in this population who are engaged in opioid substitution therapy and those who are engaged in mental health counseling have a much lower risk of re-infection when compared with those who are not receiving these services."

In the U.S., this has implications when looking at suburban and rural communities with high rates of opioid use: "Injection drug use is fueling an epidemic of hepatitis C, and people who use injected drugs account for more than 80-90% of new infections in North America."

John Ward, MD, director of the Viral Hepatitis Program for the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention of the Centers for Disease Control and Prevention (CDC), concurs that there is a problem in the addiction population and points out that younger cohorts are seeing the biggest increases in new infections.

"The CDC estimates that there were approximately 34,000 new infections in 2015," he told MedPage Today via email. "Of these, the greatest increases, and the highest overall number of cases, are among young people ages 20 to 29, with injection drug use as the primary route of transmission."

Because HCV often has few noticeable symptoms, however, the number of new cases is likely much higher than what is reported, Ward noted.

"Comprehensive approaches are needed to prevent new infections among people who inject drugs. Syringe services programs are one of many tools that communities can use to not only help reduce new infections through provision of sterile equipment but also by providing links to hepatitis C and B and HIV testing, and treatment -- to stop drug use and protect from the health consequences of viral hepatitis and HIV."

In a recent study, CDC researchers concluded that there are opportunities for states to adopt laws and policies that could help increase access to HCV preventive and treatment services, reducing the number of persons at risk for HCV transmission and disease -- especially among injection drug users.

Janjua points out that a lot of work needs to be done in communities where harm-reduction programs are often not available: "The key is to prevent both new infections and re-infections among these young populations who are injecting drugs, and also avenues to provide testing and treatment for hepatitis B, HCV, HIV." Harm-reduction services may include the availability of clean needles to prevent transmission, opioid-substitution therapy for management of addictions, addiction counseling, and a variety of social services.

This younger cohort "needs much more comprehensive care if we are to eliminate hepatitis C," he added. "Then, for the older boomer population, we need to diagnose them early in the course of disease, which means enhancing screening, and then treating them to prevent end-stage liver disease and liver cancer."

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